Background

In 1999, Crouse Hospital experienced an outbreak of MRSA in an adult critical care
unit. To keep the outbreak from spreading, MRSA patients were cohorted to one side
of the critical care unit and a dedicated nursing staff was assigned to the group.
Cohorting worked well to control the outbreak, so the hospital implemented a plan
to permanently designate a MRSA unit, complete with a dedicated nursing staff. Establishing
the MRSA unit took about a year, said manager Barbara Miller Stahl, RN.

How it works

Crouse routinely screens all high-risk patients for MRSA, including those being transferred
from nursing homes and other hospitals and those with open wounds. The 17-bed MRSA
unit houses an average of 11 patients daily who are either infected with or colonized
with MRSA. Staff assigned to the MRSA unit are not required to wear gowns but wash
their hands before and after changing their gloves between patients. Unassigned personnel
gown upon entering the unit and wash their hands before and after changing gloves
between patients. Gowns are removed on leaving the unit and are changed only in between
caring for patients who have infections with other resistant organisms. These patients
are cohorted to another area of the unit.

The unit cares for older patients with chronic illnesses as well as younger patients
with sickle-cell anemia and athletes with community-acquired infection, according
to Ms. Miller Stahl. MRSA patients who are receiving peritoneal dialysis or who need
to be on telemetry cannot be admitted to the dedicated unit, because of their need
for specialized care.

The challenges

Staff had several concerns about the new unit at first, according to Ms. Miller Stahl
and Shelley Gilroy, FACP, medical director of infection control. “Physicians
were afraid that they would become colonized or infected by treating patients in the
MRSA unit or that their patients who were colonized but not infected would become
infected if admitted to the MRSA unit,” said Dr. Gilroy.

In response to these concerns, the infection control team and nursing supervisors
explained that it was actually safer in the MRSA unit because staff are required to
wear gloves and follow precautionary hand-washing protocols, whereas in other areas
of the hospital these precautions are not routinely used before patients are diagnosed,
said Ms. Miller Stahl. “Convincing the other sections of the hospital that
this was the best place, the safest place and the greatest place to send the MRSA
patients was a real challenge,” she said.

Results

The hospital has saved more than $1 million and reduced the average length of stay
for MRSA patients from 30 days to 12 days;

Nosocomial MRSA rates decreased because of the “once positive, always positive”
policy, which calls for former MRSA patients to be readmitted into the MRSA unit rather
than the general hospital population; and

MRSA rates went from 0.66 per 1,000 patient care days in September 2000 to 0.43 per
1,000 patient care days in July 2002. Rates had decreased further to 0.25 per 1,000
patient care days as of November 2007.

Lessons learned

Accumulate data to show administrators and staff the positive effects of cohorting
MRSA patients in one unit. “The data showed that this was having a dramatic
impact on the MRSA rate in the hospital, as well as on length of stay and on hospital
spending. The hospital saved substantially just on buying fewer gowns,” said
Ms. Miller Stahl.

Isolate all MRSA patients and consider them “once positive, always positive,”
the policy at Crouse. “This is not a popular policy, but it has helped us prevent
spread of MRSA,” explained Dr. Gilroy. “It has been reported in the
literature that the majority of readmitted carriers harbor MRSA for greater than three
years.”

How patients benefit

Cristina A. Topor, MD, head of Crouse's hospitalist program, said MRSA patients get
equal—if not better—care in the dedicated unit than elsewhere in the
hospital. “These are often patients who are hospitalized several times a year,
so there is an air of familiarity among the patients and the nursing staff,”
said Dr. Topor, adding that this dynamic tends to engender more personal, attentive
care. The ability of patients to move freely about the MRSA unit is another important
and easily overlooked benefit. “If these patients were isolated in private
rooms, obviously that would not be an option,” she said.

Next steps

Dr. Topor said plans are in motion to admit patients who need telemetry. “Sometimes
heart problems develop after the patient has been admitted to the MRSA unit, and it
is very hard on the patient when they have to be moved to an isolation room elsewhere,”
she said.

Words of wisdom

While Crouse was in an ideal position to start up the MRSA unit, it makes economical
sense to separate MRSA patients even if it requires a capital investment, according
to Dr. Gilroy. “We are taking a pro-active approach, because the cost of treating
a hospital-acquired MRSA infection is much higher than the cost of the intervention
to prevent it.”

Rochelle Nataloni is a freelance writer in Sewell, N.J.

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